The focus of this blog is on the wonders of government-run health-care everywhere but I also note the damage done to private medicine by a legal system that supports predatory litigation.

The long-established socialized medicine systems in Britain and Australia are a particularly relevant warning about where such systems end up.

Posts by John J. Ray (M.A.; Ph.D.)

Saturday, November 14, 2009

Britain still killing off the infirm elderly

At least 1,800 dementia sufferers die each year from 'chemical cosh' drugs they shouldn't even be given, a report has found. Just one in five of the 180,000 dementia patients prescribed the anti-psychotic drugs benefit, meaning nearly 150,000 are given them needlessly. But one in 100 is condemned to an early death, while many more suffer debilitating side-effects, leading critics to claim the risks outweigh the benefits.

Experts believe the problem has grown worse since NHS funding was restricted to patients with 'moderate' cases of dementia in 2006. They suggest that the lack of alternative medicines for those whose symptoms are classed as 'mild' or 'severe' has increased reliance on anti-psychotic drugs. The drugs are used to sedate patients if they grow agitated, to make life easier for their carers.

These 'chemical cosh' drugs are not licensed to treat dementia but are prescribed to control associated problems such as delusions, sleep disturbance and aggressive behaviour. But the Government-commissioned report confirms fears that their long-term use aggravates other medical conditions, accelerates mental decline and causes premature death. Care services minister Phil Hope yesterday backed an action plan to cut the 'unacceptable' use of anti-psychotics by two-thirds over the next three years.

The report's author, Sube Banerjee, professor of mental health and ageing at the Institute of Psychiatry, King's College London, said up to a quarter of people with dementia are on the drugs at any time, with only 36,000 deriving any benefits. He said they should be used as a 'last resort' for three months at the lowest dose, with a review at the end of this period. He said it was a 'major NHS issue' that many people got 'relatively small' benefits compared with the potential dangers. Professor Banerjee said that 20 or 30 years ago, 30 per cent of those living in care homes had dementia, whereas 80 or 90 per cent of residents were now affected.

Pointing to the growing burden of elderly patients with Alzheimer's and similar diseases, he said: 'What we have here is an overall failure of health and social care systems to adjust to a changing world.' Professor Banerjee recommended more psychological therapies and an audit of how many prescriptions are written, as well as improved training for staff looking after dementia patients to stop them simply relying on drugs.

Mr Hope said these ideas would all be implemented, as well as the creation of a national clinical director of dementia. Neil Hunt, chief executive of the Alzheimer's Society, said: 'This goes beyond quality of care - we see it as a fundamental human rights issue. Almost 150,000 people are being inappropriately prescribed these drugs as a chemical restraint. 'The scandalous over-prescription of anti-psychotic drugs leads to an estimated 1,800 deaths a year. It must end.'

Nadra Ahmed, chairman of the National Care Homes Association, said GPs were not spending enough time visiting care homes to review medication.

Liberal Democrat MP Paul Burstow, who has led a ten-year campaign on the issue, said: 'This review comes much too late for thousands of elderly people whose lives have been cut short by the reckless prescribing of anti-psychotic drugs. 'The evidence that anti-psychotic drugs do more harm than good has been mounting for years.'

Britain is now mandating degrees for all new nurses -- but how will a degree help a frightened patient?

I see no evidence that graduates make better nurses. My fear is that too much theory risks making them ‘too posh to wash’

Nursing is one of the most admirable of all professions. I was very lucky, in my 35 years as a doctor, to work with some extraordinarily gifted nurses. They were knowledgeable, dedicated and hardworking, of course; but, on top of this, they had compassion, empathy, common sense and a 360-degree awareness of what was going on around them. And grace under pressure. It is not easy to keep your cool when several people at once are asking you questions, one or more phones are ringing, and you are reassuring a patient about to undergo an operation, trying to keep the drug round to time and making sure the medical team knows what is going on.

But there are some nurses who are simply not up to the job. And there are wards where leadership is lacking. Patient information gets lost, practices are sloppy and patients, treated with inappropriate familiarity, call in vain for bedpans. The staff appear too busy to care, and spend more time chatting to each other than talking with anxious patients.

The Patients Association receives many complaints of such inadequate, and sometimes outright negligent, treatment. Its report Patients not Numbers, People not Statistics, published in August, documented appalling cases of mistreatment.

A speech given yesterday by Ann Keen, the Health Minister, announcing a measure that would “raise the quality of patient care” should therefore be welcomed. But the measure she described may not have been precisely what the patient ordered. By 2013 anyone wishing to be a nurse will have to take a degree course lasting up to four years.

The reasons given for this — the most radical change in nurse trainingsince the NHS was founded — are not entirely persuasive or encouraging. It is designed “to raise the status of nursing”. This, alas, is a story that we have heard many times before to justify reforms in the profession but it no longer seems relevant. The ghost of the nurse as “the doctor’s handmaiden” has long since been exorcised — not least because an increasing proportion of nurses are male and the medical profession as a whole is becoming increasingly female. In many cases, nurses are the leaders of the multidisciplinary team.

Christine Beasley, the Chief Nursing Officer, has argued that, as more young people than ever are studying for a degree, this will make nursing more attractive. The logic of this escapes me. A four-year course may put off individuals who have all the necessary qualities for nursing either because they do not feel academically inclined or because they may not wish to accumulate large debts. Besides, one would hope that people would enter nursing because they are motivated to care for others rather than because they want to enter a degree course.

It has also been argued by the Department of Health that graduates would “be able to deal more readily with increasingly complex care in an increasingly challenging health and social care system”. It is not at all clear that the difference between a degree course and the existing diploma will necessarily equip nurses to function better. The kind of multitasking I referred to requires quite different qualities. At any rate, I would like to see the evidence that the 75 per cent of nurses who currently lack degrees are less capable than the remainder who have them.

Many nurses have successfully extended their roles — acting as specialists in different contexts — without a degree. They have simply had additional training as required. I have a particular reason for being grateful to specialist epilepsy nurses who vastly improved the care I was able to give to older patients with seizures. Most simply took on the extra training. Requiring all nurses to have a degree seems to be a blunt instrument for enabling some nurses to acquire new skills and take on new roles. There is no reason why some nurses should not choose to proceed to a degree after they have acquired a diploma.

There is, however, a deeper concern about the proposal. It will not address the failures of basic care that all of us have witnessed when visiting the bedsides of friends and relatives in hospital. Indeed, it may exacerbate the problem.

The emphasis on the academic aspects of nursing, rather than practical skills and the deeply humane activity of hands-on care, may constitute a kind of “dumbing up”. Focusing on more abstract and theoretical issues, which a degree course, as opposed to vocational training, would require, might diminish the commitment to basic nursing — a fear captured in the much used phrase: “too posh to wash”. This is dangerous, particularly at a time when such care is undervalued — though not by those who receive it. One could be forgiven for thinking that the rewards and prestige of nursing rise in proportion to the distance from the bedside.

Already, we are seeing core nursing activities handed over to healthcare assistants who require only an NVQ or similar qualification. Such individuals are often deeply caring and highly skilled but it cannot be good for patients to have their nursing care divided between yet more professionals — or an iron wall erected between different aspects of nursing. Experienced nurses know that they are often able to learn much more about the patient’s needs and indeed his or her condition during the course of giving a blanket bath than through a structured interview in which many boxes are ticked.

We are told that there will be “a consultation process”. However, as is customary, the main outcomes have already been decided. Though the consultation will run until the end of April, the standards will be finalised only a few months later and the first new programmes will start in the autumn of 2011.

One can only hope that this latest development in nurse training will not simply place more distance between nurses and the patients who need their care. Ann Keen’s talk of providing “new nurses with the decision-making skills they need to make a high-level judgment in the transformed NHS” doesn’t awaken the expectation that the reforms will do much for the lonely, frightened, thirsty patient sitting in a pool of urine. My concern for such a patient is not exactly disinterested. One day it will be me. Or you.

One of the world's oldest "free" hospital systems (from 1944) shows where such systems end up. They employ more bureaucrats than medical staff so the patients get the short end

EMERGENCY departments are failing to meet national performance targets in every area but non-urgent treatment, according to latest Queensland Health figures. Quarterly public hospital performance reports released yesterday showed emergency departments fell short of recommended treatment time targets for resuscitation, emergency, urgent and semi-urgent patients. The figures also revealed more than a third of Queenslanders waited in excess of eight hours for a bed in a ward after arriving at emergency departments.

Elective surgery figures showed that at October 1, 17.5 per cent (or more than 6000 patients) were still waiting longer than clinically desirable for treatment.

Defending the results Health Minister Paul Lucas said the number of long wait patients in the September quarter had decreased by 15.3 per cent compared with the 2008 September quarter. Mr Lucas said that emergency department admissions were increasing well in excess of population growth and swine flu had placed additional pressure on hospitals. "Surgeons must give priority to emergency cases and both medical and surgical emergencies use beds that would otherwise be used for elective surgery," Mr Lucas said.

Australian Medical Association Queensland president Dr Mason Stevenson said there was little good news in the report, and labelled the average wait of six hours and 20 minutes for a bed in emergency, "unacceptably high". Dr Stevenson said there was a "cascading effect of suffering" from emergency departments to elective surgery lists. "Its very frustrating for clinicians to see that patients are suffering unnecessarily as a result of unavoidable delays due to resource shortages," he said.

High priority patients at Townsville hospital waited an average of 17 days for oncology radiation – falling short of the national benchmarks of 10 working days. Mr Lucas said the three other hospitals performing the treatment, the Mater, Princess Alexandra and Royal Brisbane and Women's hospitals, had improved to easily meet the benchmark. "At Townsville there is still more work to be done . . . This report is a benchmark that identifies where our strategies are working and where we can do better."

Clearly something must be up with the AARP. Why else would the nation's largest lobbying organization, sworn to protect the interests of senior citizens, watch silently as Congress plans to cut Medicare spending by $400 billion to pay for its health reform legislation? Could it be that the interests of seniors and the AARP are not exactly aligned?

Let's follow the money. The AARP takes in more than half of its $1.1 billion budget in royalty fees from health insurers and other vendors that market services with the organization's name. Medicare supplementary policies, called "Medigap" plans, make up the biggest share of this royalty revenue.

The AARP has an interest in selling more, not fewer, Medigap plans, of course. But there is a competitor on the block. A growing number of seniors are enrolling in a new form of Medicare coverage  Medicare Advantage  where they don't need Medigap.

Medicare Advantage was created in 2003 to give seniors the option of joining private plans that are paid up to 12% more to provide better health benefits than traditional Medicare. These private plans compete with each other by offering seniors such services as lower premiums, better drug coverage, dental care and eyeglasses, and more comprehensive coverage for major medical expenses. Nearly 11 million of Medicare's 45 million beneficiaries are in the program.

Congress' health reform bills would cut spending for Medicare Advantage by at least $150 billion. President Obama has singled out Medicare Advantage, saying it is a giveaway to private insurers. But virtually all of the extra money goes back to seniors in the form of better benefits, so it's seniors who have the most to lose.

A Washington Post front-page story on Oct. 27 questioned whether the AARP has a conflict of interest in appearing to represent seniors while watching Congress cut Medicare. "Democratic proposals to slash reimbursements for ... Medicare Advantage are widely expected to drive up demand for private Medigap policies like the ones offered by AARP, according to health care experts, legislative aides and documents," the Post's Dan Eggen reported.

Medigap plans are a cash cow for the AARP. And if people don't need them because they can enroll in Medicare Advantage plans, that's a revenue loss for the AARP. While the organization has some partnering arrangements with Medicare Advantage plans, they provide a fraction of the revenue to the organization that Medigap does.

Second, if Medicare's benefits are cut by $400 billion or more, seniors will have an ever greater need for Medigap coverage. "There's an inherent conflict of interest," former AARP executive Marilyn Moon says of the AARP's royalty arrangements. "They're ending up becoming very dependent on sources of income."

Tens of thousands of seniors have resigned from the AARP, many of them cutting up their membership cards to protest the organization's promotion of health reform.

The new chief executive of the AARP, Barry Rand, who was a strong supporter of President Obama during last year's presidential campaign, says the AARP is not protesting the Medicare cuts because reducing waste and fraud in Medicare will make the program stronger over the long term.

Medicare is in dire need of modernization to make it more efficient, but savings should go back into making it more solvent. But instead of contributing any savings to the $38 trillion in long-term debt the program is facing, the bills before Congress would use Medicare funds to expand health insurance coverage to working Americans.

While expanding coverage is also a worthy goal, if the AARP were representing its members well, it would argue that the money should come from other sources. It's no wonder seniors are upset. Clearly, the interests of the AARP and the 40 million seniors it purports to represent are not aligned in the health reform debate.

As an American, I am embarrassed that the U.S. House of Representatives has 220 members who actually believe the government can successfully centrally plan the medical and insurance industries. I'm embarrassed that my representatives think that government can subsidize the consumption of medical care without increasing the budget deficit or interfering with free choice. It's a triumph of mindless wishful thinking over logic and experience.

The 1,990-page bill is breathtaking in its bone-headed audacity. The notion that a small group of politicians can know enough to design something so complex and so personal is astounding. That they were advised by "experts" means nothing since no one is expert enough to do that. There are too many tradeoffs faced by unique individuals with infinitely varying needs.

Government cannot do simple things efficiently. The bureaucrats struggle to count votes correctly. They give subsidized loans to "homeowners" who turn out to be 4-year-olds. Yet congressmen want government to manage our medicine and insurance.

Competition is a "discovery procedure," Nobel-prize-winning economist F. A. Hayek taught. Through the competitive market process, we producers and consumers constantly learn things that force us to adjust our behavior if we are to succeed. Central planners fail for two reasons:

First, knowledge about supply, demand, individual preferences and resource availability is scattered -- much of it never articulated -- throughout society. It is not concentrated in a database where a group of planners can access it.

Second, this "data" is dynamic: It changes without notice. No matter how honorable the central planners' intentions, they will fail because they cannot know the needs and wishes of 300 million different people. And if they somehow did know their needs, they wouldn't know them tomorrow.

Proponents of so-called reform -- it's not really reform unless it makes things better -- have shamefully avoided criticism of their proposals. Often they just dismiss their opponents as greedy corporate apologists or paranoid right-wing loonies. That's easier than answering questions like these:

1) How can the government subsidize the purchase of medical services without driving up prices? Econ 101 teaches -- without controversy -- that when demand goes up, if other things remain equal, price goes up. The politicians want to have their cake and eat it, too.

2) How can the government promise lower medical costs without restricting choices? Medicare already does that. Once the planners' mandatory insurance pushes prices to new heights, they must put even tougher limits on what we may buy -- or their budget will be even deeper in the red than it already is. As economist Thomas Sowell points out, government cannot really reduce costs. All it can do is disguise and shift costs (through taxation) and refuse to pay for some services (rationing).

3) How does government "create choice" by imposing uniformity on insurers? Uniformity limits choice. Under House Speaker Nancy Pelosi's bill and the Senate versions, government would dictate to all insurers what their "minimum" coverage policy must include. Truly basic high-deductible, low-cost catastrophic policies tailored to individual needs would be forbidden.

4) How does it "create choice" by making insurance companies compete against a privileged government-sponsored program? The so-called government option, let's call it Fannie Med, would have implicit government backing and therefore little market discipline. The resulting environment of conformity and government power is not what I mean by choice and competition. Rep. Barney Frank is at least honest enough to say that the public option will bring us a government monopoly.

Advocates of government control want you to believe that the serious shortcomings of our medical and insurance system are failures of the free market. But that's impossible because our market is not free. Each state operates a cozy medical and insurance cartel that restricts competition through licensing and keeps prices higher than they would be in a genuine free market. But the planners won't talk about that. After all, if government is the problem in the first place, how can they justify a government takeover?

Many people are priced out of the medical and insurance markets for one reason: the politicians' refusal to give up power. Allowing them to seize another 16 percent of the economy won't solve our problems.

There's been plenty of coverage about the outrage on the left incited by the Stupak amendment. But what lots of the MSM coverage has neglected is what should really be upsetting Americans, pro-choice and pro-life alike -- and that's the one-size-fits-all health care that Pelosi's "reforms" will impose on all of us. From a Jake Tapper report:

The office of House Speaker Nancy Pelosi, D-Calif., says that the Stupak amendment does not prohibit by law private insurance companies from offering plans that include abortion coverage to women not receiving government subsidies.

But many in the abortion-rights community say the amendment will likely have that effect because so many Americans would be receiving a subsidy, insurance companies would drop abortion coverage so as to appeal to the largest number of consumers possible.

Let's all think about what that means. By that logic, the plans open to those receiving government subsidies would effectively determine what health care benefits are available to us all -- if they don't cover it, this argument goes, no one will, for competitiveness reasons.

So just take abortion out of the equation for a minute. In effect, what the liberals and abortion rights activists are telling us is an ugly truth about the House "reform": It will effectively impose one-size-fits-all health care on Americans. The plan(s) open to those receiving government subsidies (and therefore essentially under government control) will indirectly determine what you and I will be able to get from our own private health care plan.

And on the off-chance that there remains a plan that offers more benefits but at higher cost, we'll be taxed for choosing it. Nice.

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Background

Postings from Brisbane, Australia by John Ray (M.A.; Ph.D.) -- former member of the Australia-Soviet Friendship Society, former anarcho-capitalist and former member of the British Conservative party.

This blog gives a lot of attention to events in Australia and Britain -- places where there already exist systems similar to the one most likely to befall the USA if the Democrats get their way -- "Free" medical care supposedly available to all through government hospitals but with a competing private sector as well. The Canadian system is considered too Soviet to provide a likely model for the USA

TERMINOLOGY: Many of my posts concern the very instructive state of socialized medicine in Australia. Like the USA, Germany and India, Australia has a system of State governments which have substantial independence from the central (Federal) government and it is they who are mainly responsible for "free" health services. It may therefore be useful to some for me to note the standard abbreviations for the States concerned: QLD (Queensland), NSW (New South Wales), WA (Western Australia), VIC (Victoria), TAS (Tasmania), SA (South Australia).

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Conservatives do NOT object to helping the poor. Government welfare legislation in aid of the poor was in fact first introduced by conservatives -- Bismarck and Disraeli in the 19th century. What conservatives want is for the help to be delivered in a sane manner. And anyone who thinks that government bureaucracies can run hospitals well is completely out of touch with reality.

One of the oldest "free" public hospital systems in the world is that in the Australian State where I live: Queensland. It dates from 1944 (Britain's NHS began in 1948). So its advanced state of decay reveals well where the slow cancer of bureaucracy ends up. It now has three "administrative" employees for every medical employee. All those clerks are really good at curing people, I guess! Frequent bulletins on the flailing but ineffectual attempts to "fix" the system will appear here -- as well as bulletins on the dreadful things it does to patients and the long waits they endure.

On all my blogs, I express my view of what is important primarily by the readings that I select for posting. I do however on occasions add personal comments in italicized form at the beginning of an article.

I am rather pleased to report that I am a lifelong conservative. Out of intellectual curiosity, I did in my youth join organizations from right across the political spectrum so I am certainly not closed-minded and am very familiar with the full spectrum of political thinking. Nonetheless, I did not have to undergo the lurch from Left to Right that so many people undergo. At age 13 I used my pocket-money to subscribe to the "Reader's Digest" -- the main conservative organ available in small town Australia of the 1950s. I have learnt much since but am pleased and amused to note that history has since confirmed most of what I thought at that early age.

I imagine that the the RD is still sending mailouts to my 1950s address!

NOTE: The archives provided by blogspot below are rather inconvenient. They break each month up into small bits. If you want to scan whole months at a time, the backup archives will suit better. See here or here